Failure to Address and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to follow its own grievance policy in addressing two documented grievances submitted by a cognitively intact resident with diagnoses including weakness and Parkinson's disease. The grievances, both recorded on designated forms, described concerns about nursing staff behavior during mealtimes, including inattentiveness and rudeness, as well as issues with delayed or missing condiments resulting in cold food. Both grievances were assigned to the DON with a specified resolution date, but there was no evidence that the concerns were addressed or communicated to the resident. During an interview conducted more than three weeks after the grievances were filed, the resident reported that no one had discussed the concerns with her since she raised them. She expressed a lack of expectation that her issues would be resolved, indicating a breakdown in the facility's process for acknowledging and resolving grievances as outlined in their policy. The policy requires prompt efforts to resolve grievances, keeping the resident informed of progress, and issuing a written decision, none of which occurred in this case. Further interviews with facility leadership revealed confusion regarding responsibility for grievance management. The DON stated that the NHA handled grievances, while the NHA, identified as the Grievance Official, was unaware of the specific grievance forms and had not seen the paperwork. This lack of communication and adherence to policy resulted in the resident's grievances not being addressed in a timely or effective manner.
Plan Of Correction
F585 1. Resident #29 still currently resides in the facility. The cited resident did not sustain harm from the deficient practice and is at their psychosocial baseline. Resident #29's grievances were resolved. 2. All residents were interviewed during guardian angel rounds to ensure for potential resident concerns by 6/6/2025. Those residents with concerns were provided with a resident concern form and resolved according to the facility grievance policy. 3. The facility IDT was reeducated on the facility grievance policy including grievance documentation, follow-up, and resolution by 6/6/2025. Facility grievance monitoring was added to the morning meeting template for follow-up. 4. The QAPI committee has directed the NHA/designee to perform random weekly audits of the facility grievance log to ensure grievance is resolved according to the grievance policy. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review.